HospitalInspections.org

Based on interview, facility document review, and facility policy review, the facility failed to ensure the Governing Body appointed the hospital's Chief Executive Officer (CEO) for 3 (Previous CEO #6, Previous CEO #7, and Current Interim Chief Executive Officer (ICEO) #11) of 3 CEOs since 2023. The failure had the likelihood to result in no one being responsible for managing the hospital.

Findings included:

A facility document titled, "[name of facility] Governing Board By-Laws," undated, revealed, "The Board of Directors shall appoint and the Governing Board shall confirm the Chief Executive Officer of the Hospital. The CEO shall have all the authority and responsibility necessary to operate the Hospital in all its activities and departments, subject to the advice and counsel of the Governing Board and any policies which the Governing Board may issue."

The facility's "Governing Board Meeting Minutes," dated 03/23/2023, 06/27/2023, and 09/27/2023, did not reveal evidence that Previous CEO #6 was appointed and confirmed.

An email dated 05/17/2024 at 2:06 PM from the Chief Operating Officer (COO) confirmed that Previous CEO #6 served as the CEO from 01/09/2023 to 11/17/2023.

A facility document titled, "Governing Board," dated 12/21/2023, did not reveal evidence that Previous CEO #7 was appointed and confirmed.

An email dated 05/17/2024 at 1:34 PM from the COO confirmed that Previous CEO #7 served as the CEO from 12/04/2023 to 02/12/2024.

The facility's "Governing Board Meeting Minutes," dated 03/21/2024, did not reveal evidence that Current ICEO #11 was appointed and confirmed.

During an interview on 05/17/2024 at 2:47 PM, Interim Director of Quality Management and Interim Infection Preventionist (IDQM/IIP) #1 confirmed that there was no evidence in governing board meeting minutes or elsewhere that Previous CEO #6, Previous CEO #7, or Current ICEO #11 had been appointed by the Governing Body as the hospital CEOs.

Based on record review, interview, and facility policy review, the facility failed to ensure all licensed nurses who provided services in the hospital adhered to the hospital policies for 1 (Patient #1) of 2 patients reviewed for critical laboratory results. The failure had the likelihood to result in the delay of the patient's care.

Findings included:

A facility policy titled, "Clinical Services," subject, "Critical Test Results," last revised in 07/2022, revealed, "Purpose: To provide a systematic approach for timely communication of critical test results among health professionals." The policy also indicated, "Communication Responsibility: 1. Members of each discipline will be responsible for accurate and timely communication of critical value and test results to the appropriate licensed practitioner as per the attached Appendix." The policy revealed a graph titled, "Critical Test Results Appendix" with the words "REPORT WITHIN 30 MINUTES OF RECEIPT" at the top of the graph. The graph contained a list of laboratory tests with their corresponding critical values. A Hemoglobin test result of "< [less than] 8 g/Dl [grams per deciliter]" was listed as a critical result.

The "History and Physical" section of Patient #1's medical record revealed that the facility admitted the patient on 05/23/2023 with the diagnosis of respiratory failure. The medical record also revealed a "CBC [Complete Blood Count] AUTO DIFFERENTIAL" laboratory test that resulted on 06/22/2023, at 7:25 AM, with a hemoglobin value of 7.6 g/Dl.

A "Provider Notification" flowsheet for Patient #1 revealed no evidence that the provider was notified of the patient's 06/22/2023 CBC laboratory results, which showed a 7.6 g/Dl hemoglobin value.

During an interview on 05/17/2024 at 11:48 AM, Registered Nurse (RN) #10 said the provider should be notified of critical results within 30 minutes, and if the provider did not call back within 15 minutes, the nurse should call again.

During an interview on 05/17/2024 at 12:17 PM, Interim Director of Quality Management and Interim Infection Preventionist (IDQM/IIP) #1 confirmed that on 06/22/2023, Patient #1's hemoglobin laboratory test resulted, and was 7.6 g/Dl. IDQM/IIP #1 acknowledged that the policy for critical hemoglobin was less than 8 g/DI and confirmed that there was no documented provider notification for the lab result.